The Child with Alterations in Cerebral Function
The Child with Alterations
in Cerebral Function
Neurologic Assessment
VS • HR, BP, Respirations,
Temperature
LOC • Orientation
• Pediatric Glasgow Coma Scale
Eyes • Pupillary response and
movement, extraoccular movement, visual disturbances
Reflexes
HC in infants
Motor /Sensory Function • Tactile and painful
stimuli
• Spontaneous activity
• Response to pain
• Twitching/seizures
Physical Assessment
Reflexes
• Kernig’s Sign
• Brudzinski’s Sign
• Both sign of meningeal irritation
Posturing
• Decerebrate
• Decorticate
Intracranial pressure (ICP)
Pressure within the cranium that
surrounds the brain
Normally 4-12 mm
Pressure is caused by the volume of
brain mass, CSF and blood
• An increase in anyone of these must be
compensated for by the others
Causes of Increase ICP
Tumors
Accumulation of CSF
Intracranial bleeding
Cranial cerebral
trauma
Hydrocephalus
Brain tumor
Meningitis/
Encephalitis
Intracerebral
hemorrhage
Clinical Manifestations of ICP
Infants
• Tense bulging fontanel
• Separated sutures
• Macewen Sign
• Setting sun sign
• Irritability
• High pitches cry
• Changes in feeding
Children
• Headache
• N&V
• Diplopia
• Seizures
• Cognitive, behavioral
and personality signs
Late Signs of Increased ICP
Lethargy-coma
Posturing
Cheyne stokes respirations
Decreased pupil size and reaction
Decrease response to commands/stimuli
Nursing Care of the
Unconscious Child
Assess VS for Changes
Decrease ICP
• Elevate HOB 15-45 degrees
• Keep head midline
• Prevent constipation
• Provide quiet, low stim environment
• Therapeutic touch
Nursing Care of the
Unconscious Child
Maintain patent airway/prevent cerebral hypoxia
• Positioning, O2, oral airway
Administer sedatives or anticonvulsants as prescribed
Osmotic Diuretics or corticosteroids
Prevent skin breakdown
Monitor Intake and Output
Family Support
Seizures
Disturbance in normal brain functioning
Abnormal electrical discharge of brain
LOC, uncontrolled body movements,
staring, changes in behaviors
Generalized, Partial or focal, Absence
Status Epilepticus
Continuous seizure activity, generalized
lasts >30 minutes
Danger of cardiac, respiratory arrest,
brain damage
Airway, O2 administration, hydration,
medication/treatment
Seizures
Precautions
• Side rails up,
padded
• Safety
• Wear helmet
• O2 , Sx at BS
• Prevent exposure to
triggers
Nursing Care • Protect child, do not
restrain
• Do not put anything in mouth
• Loosen restrictive clothing
• Remain with child
• Administer meds as ordered; O2
Documentation of Seizure
Activity
Trigger if any, aura
Time seizure began and ended
Clinical manifestations of the seizure
Any interventions
VS during event
Post seizure behavior and symptoms
Child and Family Education
What to do if child has seizure,
Safety and when to call EMS
Wear med alert bracelet
Activity restrictions, • Encourage normal lifestyle
• Ketogenic Diet (high fat, low carb, low protein)
Medications and side effects • Do not d/c or switch
• Dilantin, Phenobarb, Carbamazepine
Febrile Seizures
Occurs between 6 mos- 3yrs most frequently; can reoccur
Related to how quickly the temp rises not necessarily how high the temp goes
Possible genetic predisposition
Accompany GI or URI
Treat fever
Head Trauma
Skull fx, contusions, hematomas
Complications include: ICP, infection, cerebral edema, herniation
Epidural – blood accumulates between the dura & skull (LOC- normal period-lethargy or coma)
Subdural- b/t dura and cerebrum develops more slowly • Common in infants as result of birth trauma
Clinical Manifestations of
Head Injury
Minor Injury
• LOC (maybe)
• Transient period of
confusion
• Somnolence
• Irritability
• Pallor
• Vomiting
Severe Injury
• S/S ICP
• Retinal hemorrhage
• Hemiparesis/quadrplegia
• Increased temp, unsteady
gait, papilledema
• Progression of injury
• Altered Mental status
• Increased agitation
• Marked changes in VS
Nursing Considerations
for the Head Injured Child
Monitor LOC with Pediatric Coma Scale
Monitor VS & Neuro Checks frequently
• Hypoxia, decreased perfusion, shock , ICP
• Cushing’s triad (late sign)
• Increased systolic blood pressure
• Bradycardia
• Irregular respirations
Nursing Considerations
for the Head Injured Child
Monitor O2- continuous pulse ox
Administer O2 keep sats>95%
Seizure precautions
Good positioning, quiet environment,
control body temp
Medications
Hydrocephalus
Imbalance in the production and
reabsorption of CSF: CSF accumulates
and causes dilation of ventricles
• First two years of life- developmental defect;
Older children- space occupying lesion,
hemorrhage, infection;
• communicating (impaired absorption)
• non communicating (obstruction)
Hydrocephalus
Treatment
Remove obstruction and place shunt
Complications of Shunts
• Infections
• malfunctions
Clinical Manifestations
Infants
• Increased H.C.
• High pitched cry
• Bulging fontanel
• Irritability when awake
• Seizures
Children
• S/S Increased ICP
• H/A on awakening
improvement with
emesis
• Ataxia, irritability,
lethargy, confusion
Nursing Considerations
Assess for S/S Increase ICP
Position child on side to facilitate
drainage
After surgery keep child flat 24 hours
Monitor I&O
Administer antibiotics- S/S infection
Encourage age appropriate activities
Meningitis
Most common infection of CNS;
inflammation of the meninges
Viral
• Vial agents or enteroviruses
Bacterial
• H. Flu, strep pneumoniae, neisseria
meningitides (meningococcal)
Clinical Manifestations
VIRAL
Infant - Toddler • Irritability, lethargy
• Vomiting
Older Child • Non specific illness
• h/a, malaise, muscle aches, N/V
• Photophobia
BACTERIAL
Infant – Toddler • Poor feeding/suck
• Vomiting
• High pitched cry
• Bulging fontanel
• Hyper or hypothermia
• Poor muscle tone
Clinical Manifestations
Older Child
• Abrupt onset fever,
chills, h/a
• Nucchal rigidity
• Vomiting, altered
sensorium
• Positive Kernig’s or
Brudzinski's sign
• Opisthotonus
Diagnosis
• Lab findings
• LP
Nursing Diagnosis
• Ineffective breathing
pattern
• Pain
• Injury
• Thermoregulation
Therapeutic Management
Isolation (if bacterial)
Initiation of antibiotic therapy
Monitor for and reduce ICP
Control fever/seizures
Treat complications
Pain management
Encephalitis
Inflammation of the CNS producing
altered fx in the brain and spinal cord
Can occur w/ direct invasion of a virus
or after a viral disease
S/S focal seizures and other
neurologic
Tx: supportive, neurologic monitoring,
administration of meds
Reye Syndrome
Metabolic encephalopathy develops after a
mild viral illness (chicken pox)
Fatty degeneration of the liver
5 stages
• Vomiting and lethargy
• Combativeness/confusion
• Coma, decorticate posturing
• Seizures, loss of deep tendon reflexes, respiratory
arrest
Assessment/Treatment
VS/ Neuro Assessment
Abrupt changes in LOC
Elevated liver enzymes
and ammonia levels,
decrease Glucose,
increase PT normal bili
Dx Liver biopsy
Fluid restriction
I& O, labs
Monitor for cerebral
edema
Drug management
• Corticosteroids
• Mannitol,
barbiturates
• Phenytoin
• Vit K